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Kim Posted Sat 07th of January, 2017 12:20:11 PM
Is modifier 33 to be used on the facility side or just pro-fee side? Is a surveillance colonoscopy considered a preventative screening under the affordable care act or is it up to the payor to interpret and decide? We are having discussions on the use of modifier 33 or PT for surveillance colonoscopies as per Coding Clinic for facilities this is coded to a screening but should we be using modifier 33 or PT? A lot of payors still accept PT modifier but we are unsure about using 33 or PT for surveillance? we understand that a patient who comes in for their initial screening preventative colonoscopy use 33 modifier for commercial but not sure on a surveillance? any help would be appreciative as there is no consistent coding advice that we have seen.
SuperCoder Answered Mon 09th of January, 2017 05:17:02 AM

Hi,

The 33 and the PT are for use on non-preventive codes when service was performed for preventive reasons. The 33 is for commercial payers for any service that meets the definition of a task force A and B preventive service.

Per the USPSTF (U.S. Preventive Services Task Force), “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.”

For example: if patient is returning after 3 yrs for follow-up and doctor did a 45385 to remove polyps, then it will be considered as Therapeutic Colonoscopy with modifier –PT (if Medicare) or -33 (if commercial).

According to ICD-10 CM Guidelines for Coding and Reporting CY 2017, “Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram).”

So, Screening is done for early detection and early treatment for those individuals who found positive for the disease during the screening.

The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.

Following USPSTF recommendations, the ACA preventative guidelines state patients with a personal history of adenomatous polyps and/or colon cancer are not covered under a screening guidance, but rather under a surveillance regimen. Many third-party payers also have incorporated the personal history, shortened interval surveillance colonoscopy concept into their policies.

Surveillance colonoscopies are most often covered under diagnostic benefits, even if the patient is asymptomatic. Guidelines are inconsistent across payers; check with your individual payers for their guidelines.

 

Thank you!

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